Provider Demographics
NPI:1326805813
Name:BRADEN, JACOB (MS, PLPC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BRADEN
Suffix:
Gender:M
Credentials:MS, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2013
Mailing Address - Country:US
Mailing Address - Phone:541-650-1485
Mailing Address - Fax:
Practice Address - Street 1:1771 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1151
Practice Address - Country:US
Practice Address - Phone:427-597-4881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024006573101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health